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ORIGINAL ARTICLE

Regional anaesthesiawith sedation protocolto safely debride sacralpressure ulcersDaniel K O’Neill, Bryan Robins, Elizabeth A Ayello, Germaine Cuff, PatrickLinton, Harold Brem

O’Neill DK, Robins B, Ayello EA, Cuff G, Linton P, Brem H. Regional anaesthesia with sedation protocol to safelydebride sacral pressure ulcers. Int Wound J 2012; 9:525–543

ABSTRACTA treatment challenge for patients with sacral pressure ulcers is balancing the need for adequate surgicaldebridement with appropriate anaesthesia management. We are functioning under the hypothesis that regionalanaesthesia has advantages over general anaesthesia. We describe our regional anaesthesia protocol forperioperative and postoperative management.

Key words: Anaesthesia • Pressure ulcer • Regional • Sacral • Wound

INTRODUCTIONA pressure ulcer can be defined as a ’localisedinjury to the skin or underlying tissue, usu-ally over a bony prominence that resultsfrom pressure, including pressure associatedwith shear’ (1). These ulcers can be exten-sive with damage to the skin and under-lying soft tissue, muscle and even exposing

Authors: DK O’Neill, MD, Department of Anesthesiology, NewYork University School of Medicine, New York, NY 10016, USA;B Robins, BS, NYU-NIH Summer Program, New York UniversityLangone Medical Center, New York, NY 10016, USA; EA Ayello,PhD, RN, ACNS-BC, CWON, MAPWCA, FAAN, Faculty, ExcelsiorCollege School of Nursing, The John A. Hartford Institute ofGeriatric Nursing, New York University College of Nursing,New York, NY, USA; G Cuff, BSN, MPH, CCRP, Department ofAnesthesiology, New York University Langone Medical Center,New York, NY 10016, USA; P Linton, MD, Department ofAnesthesiology, New York University School of Medicine, NewYork, NY 10016, USA; H Brem, MD, Division of Wound Healingand Regenerative Medicine, Department of Surgery, WinthropUniversity Hospital, Mineola, NY, USAAddress for correspondence: DK O’Neill, MD, Departmentof Anesthesiology, New York University School of Medicine, NewYork, NY 10016, USAE-mail: [email protected]

bone (2). These wounds may go unnoticed forextended periods of time because they are more

Key Points

• more than 90% of the pressureulcer diagnoses were a sec-ondary diagnosis relating fromanother principal problem

• it is vital that these ulcers areproperly diagnosed and treated

prevalent in bed bound, paralysed patients aswell as patients older than 65 years (2). Theannual occurrence of these pressure ulcers isapproximately 1·3–3 million (3), including over500 000 hospitalisations where pressure ulcerswere diagnosed (4). Nearly three out of fourextended stays were in people over 65 years ofage (4), and this age group also accounted for56·5% of principal diagnoses as well. More than90% of the pressure ulcer diagnoses were a sec-ondary diagnosis relating from another princi-pal problem (4), costing hospitals $10·2 billionin addition to the $752 million caused by pri-mary pressure ulcers (4). Pressure ulcers causelonger hospital stays (4) and increase the riskof infection on top of the treatment costs out-lined above (5). There is substantial evidencethat supports the fact that pressure ulcers arealso associated with increased mortality andmorbidity rates (6) and are the cause of deathin more than 104 000 persons per year in theUSA alone (7). Therefore, it is vital that theseulcers are properly diagnosed and treated.

© 2012 The AuthorsInternational Wound Journal © 2012 Blackwell Publishing Ltd and Medicalhelplines.com Inc 525

Regional anaesthesia with sedation protocol

Challenges in healing sacral pressureulcersPressure ulcers in adults usually occur overbony prominences such as the sacrum or theheel (8,9). The sacrum located in the lower

Key Point

• the vital aspect in the painmanagement and treatment ofchronic wounds is first makingthe decision to perform the sur-gical debridement then findingthe most effective mixture oftopical, subcutaneous and sys-temic anaesthesia

dorsum is the most common site for pressureulcers, where approximately 32% of pressureulcers occur according to one study (10). Ofthe newest category of pressure ulcers asdefined by the National Pressure Ulcer Advi-sory Panel (NPUAP) (1), suspected deep tissueinjury is surprisingly more commonly foundon the heels (41%) rather than on the sacrum(19%) (11). Once these ulcers are formed, theymay become chronic wounds with physiologi-cal impairments that prevent the stimulation ofwound healing even further (12-14). The bloodsupply to the sacral region defines an angio-some. Compromised blood supply from pres-sure, hypothermia and vasopressors can bothcontribute to the development of sacral pres-sure ulcers, as well as impair the angiogenicresponse during wound healing. Sharp surgicaldebridement promotes wound bed preparationfor closure. The angiogenic response is depen-dent upon where the region is anatomically andthat the response is significantly skewed awayfrom the lower dorsum (15,16). This decreasedangiogenic response contributes to the slowerhealing in the lumbosacral area (17), whichincreases the likelihood of the need for sur-gical intervention in a sacral pressure ulcer.A sacral pressure ulcer is in close proxim-ity to the rectum, which increases the likeli-hood of fecal contamination from incontinenceand can hinder healing in addition to mak-ing the wound larger (18,19). According to aprotocol for the comprehensive treatment ofpressure ulcers (2), these aspects make sacralpressure ulcers a prime candidate for operativedebridement to allow tissue regeneration tostart (20,21). Sharp debridement using a scalpelis the preferred method used to eliminate thenecrotic tissue, which hinders the healing pro-cess and possibly masks other factors suchas infection that impede wound closure aswell (2). The National Pressure Ulcer Advi-sory Panel (NPUAP)/ European Pressure UlcerAdvisory Panel (EPUAP) Clinical Guidelinesrecommends that the vascular status and sta-bility of eschar heel ulcers be determined priorto sharp debridement (1). The vital aspect inthe pain management and treatment of chronicwounds is first making the decision to perform

the surgical debridement then finding the mosteffective mixture of topical, subcutaneous andsystemic anaesthesia (22).

The role of surgery in treating sacralpressure ulcersSurgery has inherent risks. Many patients, fam-ily members and attending physicians believethat taking patients to the operating room forsurgery and anaesthesia is excessively riskycompared with medical therapy. The woundpatient has more comorbidities and is at greaterrisk than a normal average patient as evidentby the fact that wound patients have an aver-age score of 3·09 on the American Society ofAnaesthesiologists (ASA) physical status clas-sification scale (Table 1) compared with theoverall average of 2·03 value for anaesthesiapatients at a major university hospital (23). TheASA score does increase with severity of dis-ease and the impact on function. The ordinalscale is based on an assessment of the entirepresent health condition of the patient dur-ing the preoperative evaluation. The numberof comorbidities does combine to increase thescore, but it is not linear. For example, a singledisease with end-organ damage (like end-stagerenal disease requiring dialysis), which impairsfunction places a patient at higher periopera-tive risk than six relatively benign problemssuch as a lipoma or pin worms.

The incidence of complications and mor-tality for patients who undergo anaesthe-sia is greater among patients with a higherASA score (24). However, sharp surgical

Table 1 American Society of Anaesthesiologists physicalstatus classification

Class Patient Status

I Healthy patient with no comorbiditiesII A patient with mild systemic disease that should not

affect anaesthesia and surgeryIII A patient with a severe systemic disease that requires

special care during surgeryIV A patient with a severe systemic disease or end-organ

damage that is life threatening and which must beaddressed preoperatively, intraoperatively andpostoperatively by the anaesthesia team

V A moribund patient whose life expectancy does notexceed 24 hours irrespective of surgery

Adapted from American Society of Anaesthesiologists. ASAphysical status classification system. Available at: http://www.asahq.org/clinical/physicalstatus.htm

© 2012 The Authors526 International Wound Journal © 2012 Blackwell Publishing Ltd and Medicalhelplines.com Inc


debridement is necessary to remove sourcesof infection and sepsis from the wound thatwill increase mortality rates or prevent woundclosure (10). This procedure has been describedin detail and has been shown to be safe andhave low-mortality rates even in patients withmultiplecomorbidities (10).

The formation of new pressure ulcers is alsosomething to consider when evaluating therisks of surgery. Between 4·7% (25) and 45%(26) of surgical patients are at risk of developingpressure ulcers, where the only reliable indica-tor was the length of surgery. This is becauseof the fact that patients are immobile and can-not feel pain caused by an extended periodof pressure and shearing forces (27). In addi-tion, an awake patient can position themselvescomfortably on the operating room table, butanaesthetised patients lack the motor controlto adjust their position to relieve these forcesand prevent pressure injuries (27). Therefore, alengthy procedure makes the operating tablean ideal place to develop new ulcers especiallyin the presence of elderly frail skin, hypother-mia and haemodynamic instability requir-ing vasopressors (27). Special techniques forpatient positioning are used including paddingto decrease the risk of skin breakdown. Becausedebridement procedures are usually brief,anaesthesia protocols that minimise durationand depth of sedation are preferred. The oper-ating room provides a safe environment forpatient care. The surgeons have the benefitof highly skilled nursing and technical staff,modern equipment, adequate lighting, sterilesurgical field and professional anaesthetic care.Although many may claim that sacral ulcerscan be debrided ’at the bedside’ to minimise theuse of operating room resources, patients maydevelop sepsis from inadequately treated infec-tions including osteomyelitis and myositis.This surgical infection diagnostic challenge isanalogous to differentiating cellulitis which canbe treated medically and necrotising fasciitiswhich needs to be treated surgically. The ’con-servative’ strategy of ’benign neglect’ by avoid-ing surgical intervention may be ’cost effective’for policy makers who tolerate attrition likehospice rather than promoting wound healing.

Financial concernsThe financial burden for both the patient andthe hospital to bear for a surgical procedureis significant. Perioperative costs account for

5-6% of total hospitalisation costs (28,29). Thesecosts result from expensive intraoperative pro-cedures, medications, staffing and physiologi-

Key Points

• sharp surgical debridement isnecessary to remove sources ofinfection and sepsis from thewound that will increase mor-tality rates or prevent woundclosure

• the operating room providesa safe environment for patientcare

• we describe general anaesthe-sia in some detail because manysurgeons erroneously believethat all sedated patients areunder general anaesthesia

cal monitors, which places them at the forefrontof intense health care industry scrutiny (30).One method to cut costs to both anaesthesiadepartments and hospitals would be todecrease Postanaesthesia Care Unit (PACU)and postoperative admissions by investigatingthe types of anaesthetic techniques (31).

The post-anesthesia care unit (PACU) orrecovery room is essential for stabilisationand management of most surgical patients.Decreased PACU stay and postoperativeadmissions have been shown to be benefitsof increased use of regional techniques ver-sus general anaesthesia techniques (31). Whenspinal anaesthesia was used as an alternativeto general anaesthesia in knee arthroscopies(an outpatient procedure), there was no dif-ference in the readiness for discharge (32).The spinal anaesthesia group had lower painscores and no nausea and vomiting comparedwith a 19% incidence of these symptoms in thepatients who received general anaesthesia (32).Another study on anterior cruciate ligamentrepairs found an increase in PACU bypassingafter the use of peripheral nerve blocks forpostoperative pain management as opposedto general anaesthesia (33). Therefore PACUbypassing and shorter PACU duration can beaccomplished by reducing postoperative painincidence, nausea, vomiting and other postop-erative complications, especially with regionalanaesthesia (32). We describe general anaes-thesia in some detail because many surgeonserroneously believe that all sedated patientsare under general anaesthesia. In addition,general anaesthesia is required when regionalblocks fail to provide adequate antinocicep-tion or are unable to provide the operatingconditions needed for surgical success. When alocal infiltration block is administered for sacraldebridement, the recovery would primarilybe dependent upon the duration of action ofthe intravenous (IV) anaesthetics. When spinalanaesthesia is used, for example, in a spinalcord patient to decrease the risk of autonomichyperreflexia, the sensory and motor functionof the spinal cord should return to the baselinestate. Knowledge of complete or incompletespinal cord function would be necessary toattain preoperatively. The duration of actionof the intrathecal sodium channel blocker may



vary from 40 to 50 minutes for plain procainefrom 180 to 240 minutes for dibucaine withepinephrine. During the duration of resid-ual neuroaxial blockade, special additionalcare needs to be maintained to protect injuryespecially to the skin and peripheral nervesof the lower extremities. The Bromage scale isused commonly to grade block recovery.

Anaesthesia for pressure ulcer patientsThe sparse literature about anaesthesia proto-cols for wound care, especially for pressureulcers, provides limited guidance as to thebest method given the wide variation in tech-niques available (34). Sacral pressure ulcers

Key Points

• on the basis of the litera-ture surrounding the benefitsof regional anaesthesia, it is theconclusion of this wound heal-ing and regenerative medicineteam, that a protocol of aregional block with sedation asneeded is the most effectiveanaesthesia regimen for sharpsurgical debridement

• this literature review also exam-ined financial data that lookedat the costs of regional com-pared with general anaesthesiatechniques by looking at severalcost drivers in the preoperative,intra operative and postopera-tive costs

can be debrided in the lateral or prone posi-tion with local, regional or general anaesthesiawith various degrees of sedation and air-way management (34). Sacral pressure ulcersdemand significantly different anaesthesia reg-imens than other pressure ulcers, because theycould be outside the scope of certain anaesthe-sia treatments that could be applied to otherpressure ulcers (34). The anaesthesia techniqueis usually determined and applied based onthe preference of the anaesthesiologist aftercompleting the preoperative anaesthesia eval-uation. This practice often leads to a commonmisconception that anaesthesia refers to onlygeneral anaesthesia even when regional blockscan be and are used (35). On the basis of theliterature surrounding the benefits of regionalanaesthesia, it is the conclusion of this woundhealing and regenerative medicine team, thata protocol of a regional block with sedationas needed is the most effective anaesthesiaregimen for sharp surgical debridement (35).This is because it limits complications, reducespostoperative pain and decreases the eco-nomic burden placed on both the health carestakeholders and the patient. This protocolacknowledges the limitations of regional anaes-thesia and realises that pre-existing conditionsor failed blocks require the anaesthesiologist tore-evaluate the anaesthetic technique (35).

METHODSLiterature reviewAs a result of a comprehensive study ofthe literature pertaining to both regional andgeneral anaesthesia, we compiled this proto-col, which functions to give guidelines onproper application and management of the care

from the preoperative evaluation through thepostoperative care. This literature review alsoexamined financial data that looked at the costsof regional compared with general anaesthesiatechniques by looking at several cost drivers inthe preoperative, intraoperative and postoper-ative costs.

Protocol for the administration of ananaesthesia regimen to a sharpdebridement candidateIt must be emphasised that our protocol forpreventing the appearance of new pressureulcers and promoting healing of existing sacralpressure ulcers using sharp, surgical debride-ment and anaesthesia (Table 2) is designed tomaintain homeostasis during times that wouldotherwise be traumatic for both the patient aswell as the patient’s family. The protocol is ini-tiated when the surgeon decides to schedule asurgical procedure in the operating room.

Acknowledge that every patient with pressureulcers has comorbidities, which increase therisk associated with anaesthesia

Pressure ulcers are caused by unrelieved pres-sure, which obstructs blood flow creating adeficiency of oxygenation and nutrients creat-ing tissue destruction (2,3). Therefore, certaincomorbidities are associated with the forma-tion of these pressure ulcers. These comor-bidities must be accounted for, and theycomprise risk factors for anaesthesia compli-cations. A frequent risk factor associated withthe formation of a new pressure ulcer is lim-ited mobility, which results from amputations,paralysis, neurological disorders (multiplesclerosis, Alzheimer’s, dementia, etc.), comaor sedation, and so forth (36). These might notbe direct risk factors for anaesthesia, but theydo influence certain factors of the overall treat-ment and pain management with analgesia.

Pressure ulcers are also associated withmalnutrition, which could be caused by eat-ing disorders, dehydration or dietary restric-tions (36). Indices of nutritional status includealbumin, prealbumin and cholesterol. Malnu-trition is important for the anaesthesiologistto take into account including drug dosinggiven the changes in volume of distribution,protein binding to α–1 glucoprotein and phar-macodynamic effects to decrease the risk ofproblems. One study found electrolyte imbal-ances and significantly slower heart rates



Table 2 Protocol for anaesthesia administration for surgical debridement of sacral pressure ulcer © O’Neill & Ayello 2012

1 Acknowledge that every patient with pressure ulcers has comorbidities which increase the risk associated with anaesthesia.2 The preoperative assessment begins with the medical history, physical examination, laboratory analysis and consultation of

medical specialists as indicated.3 The expectation of the consultant is to characterise the disease, medically optimise and risk stratify the patient prior to

surgery and anaesthesia.4 All laboratory results and diagnostic studies are evaluated for abnormalities and are corrected as indicated.5 All patients with cardiac rhythmic management devices (CRMD) are interrogated to ensure proper functioning.6 To decrease the risk of aspiration pneumonia from gastric regurgitation, Nothing Per Os (or mouth) orders are enforced.7 Intravenous (IV) fluids and medications are administered preoperatively for inpatients, diabetics and those who need

medications.8 All patients are monitored intraoperatively according to American Society of Anaesthesiology (ASA) standards.9 Regional anaesthesia (local, peripheral and central) with sedation (none, light or deep) is administered as the default

regimen with general IV or inhalational agents used when blocks are not carried out.10 Goals of airway management are to maintain airway patency, oxygenation and ventilation using the minimum invasiveness

of airway devices.11 All patients are monitored postoperatively for duration appropriate to their acuity.

during preoperative assessments comparedwith healthy patients (37).

Pressure ulcers are also linked with manyother conditions that can severely compli-cate an anaesthesia regimen. These includediabetes mellitus, vasculitis and other vas-cular collagen disorders, immunodeficiency,corticosteroid therapy, congestive heart fail-ure, malignancies, end-stage renal disease andchronic obstructive pulmonary disease (36).All of these conditions have implications forsurgery and wound healing.

The preoperative assessment begins with themedical history, physical examination,laboratory analysis and consultation ofmedical specialists as indicated

The preoperative assessment has becomecrucial, as the role of the anaesthesiologisthas expanded outside of the operating roomand an increased number of ambulatoryprocedures, such as surgical debridement, areperformed (38). It is also vital in securing thesafety of the patient during the admission ofan anaesthesia regimen. The Australian Inci-dent Monitoring Society concluded that 3·1%of complications were directly attributed todeficient, and 11% to inadequate preopera-tive assessments (38). Davis determined that53 of 135 patient deaths (39%) linked to anaes-thesia resulted from inadequate preoperativeassessments and suboptimal monitoring ofexisting medical conditions (39).

The preoperative assessment needs tobe thorough and complete to ensure the

maximum protection for both the patient andthe institution. The evaluation begins withthe medical history then proceeds to physicalexamination, laboratory analysis and finallyto consultation of medical specialists as indi-cated by the attending anaesthesiologist. Thephysical examination takes vital signs and con-

Key Point

• the preoperative assessmenthas become crucial, as the roleof the anaesthesiologist hasexpanded outside of the operat-ing room and an increased num-ber of ambulatory procedures,such as surgical debridement,are performed

firms the presence of any conditions that couldcompromise the patient intraoperatively. Labo-ratory tests are ordered as necessary to discoverany underlying conditions that could compli-cate the procedure and explain any abnormali-ties observed during the physical examination.History of malignant hyperthermia (MH) byquestionnaire or interview requires avoidanceof triggering agents such as succinylcholineand potent inhalational anaesthetics such asisoflurane, sevoflurane or desflurane. Familyhistory of MH should prompt a call to theMH hotline and diagnosis by muscle biopsy.A questionnaire or muscle biopsy about anaes-thesia history in the patient and family is alsouseful for diagnosing the risk of MH. Further-more, a consultation is usually necessary andbeneficial to the operative care of a patientand is usually ordered to clarify any existingmedical issues.

The expectation of the consultant is tocharacterise the disease, medically optimiseand risk stratify the patient prior to surgeryand anaesthesia

Preoperative consultations should be initiatedfor the diagnosis, evaluation and treatmentof a newly or poorly managed condition and



for the creation of a risk evaluation that thepatient, anaesthesiologist and surgeon can useto make patient care decisions (38). The personrequesting the consultation should ask spe-cific questions about the patient health statusand the tasks that need to be performed priorto the procedure. The result of the consulta-tion should be a descriptive letter or progressnote summarising the patient’s medical condi-tions, along with the results of the diagnostictests (38). Omitted data about the patient’s con-dition could delay surgery and increase costs.Occasionally, an anaesthesiologist will receivea handwritten note from a medical consultantwhich reads ’Patient is cleared for surgery’.This substitute for a proper evaluation andassessment is not only useless, but is insultingto the anaesthesiologist who is responsible forclearing the patient for the operating room. Fora pressure ulcer, one consultant must be thewound care specialist or operating surgeon.Other specialists could include internist, cardi-ologist, pulmonologist, nephrologist, haema-tologist, neurologist and/or rheumatologist.The diagnostic results that accompany the let-ter are vital for the anaesthesiologist’s abilityto make an independent, unbiased decisionabout patient risk and to plan the anaesthesiaregimen accordingly.

All laboratory results and diagnostic studiesare evaluated for abnormalities and arecorrected as indicated

Laboratory examinations should only be pre-scribed to patients who present an increasedrisk of complications based on medical historyor the physical examination. This will helpto keep costs down and preserve valuablematerials (28–31,40). Each institution shoulddevelop standards which are in alignmentwith national guidelines and individual patientneeds. When preoperative test results areabnormal, correcting the abnormality reducesthe risk of developing perioperative compli-cations. Testing is most efficient when themost sensitive and specific tests are usedto confirm an existing abnormality that wasuncovered during the initial medical historyand physical examination (40). The followingtests should be ordered for the preanaes-thesia evaluation when appropriate: electro-cardiogram (ECG), echocardiography, stresstests, angiography, chest X-rays, pulmonary

function tests, complete blood count, typeand screen (T&S), coagulation studies [pro-thrombin time (PT), international normalizedratio (INR), activated partial thromboplastintime (APTT)], serum chemistries, urinalysisand pregnancy tests (41). Surgical patients canbleed to a point of requiring blood products.Therefore, a T&S would be indicated to excludethe risk of antibodies and antigen–antibodyincompatibility which may delay blood prod-uct volume resuscitation during haemorrhage.Electronic cross matching has recently beenintroduced to improve the efficiency and effec-tiveness of the process. During surgery, thehaemostatic balance between bleeding andclotting needs to be addressed to minimise therisk of haemorrhage, stroke, deep vein throm-bosis (DVT) and pulmonary embolism. Thecoagulation cascade and platelet function areboth important to evaluate in the preoperativeassessment of risk. Most surgeons are fine withINR below 2·2, but platelets may need to beordered. All substances that increase bleedingrisk that a patient is taking including antico-agulants, antiplatelets and some herbals needto be considered. For example, some patientsmay not report that they are taking herbalsthat have haemostatic impact like garlic. Clin-ical decision support should be available forstaff because the list of agents influencing thehaemostatic system continues to grow.

All patients with CRMD are interrogated toensure proper functioning

A cardiac rhythm management device (CRMD)is an implanted pacemaker (PM) or animplanted cardioverter-defibrillator (ICD) (42).Patients with these devices are at risk of devel-oping complications during surgery becauseof the malfunction of the device (42–45). Forexample, the electrocautery can be sensed by anICD which would trigger inappropriate elec-trical therapy (defibrillation) which would notonly be painful or hazardous for the patient,but could prematurely deplete the generatorpower supply (45).

Successful perioperative procedures withCRMD patients depend on the preoperativeevaluation (45). After acknowledging that thepatient has a CRMD, device testing consistsof determining the type and manufacturerof the device, determining if the patient isPM dependent for antibradycardia function



and understanding the function of the devicein the perioperative patient (42–47). Directinterrogation of the CRMD by a device expertlike a cardiac electrophysiologist or corporaterepresentative remains the ’gold standard’ fordetermining the battery status, quality of theleads and appropriateness of the settings at thetime of interrogation (48). It is imperative thatthis device interrogation data be acquired anda therapeutic plan is established in a timelymanner for optimal perioperative care (45).

The preoperative evaluation should bebased on the ASA guidelines. This includes(1) determining the extent of electromagneticinterference (EMI) during the debridement,(2) determining any adjustments to the CRMDprogramming that are needed, (3) suspendingantitachyarrhythmia functions if present,(4) advising the surgeon of the use of a bipolarelectrocautery system or ultrasonic scalpel tolimit EMI on generators and leads, (5) assuringthe operating room has temporary pacingand defibrillation machines available and(6) evaluating the possible impact of anaesthe-sia on CRMD function in the patient (44,46). Ingeneral, PM function should be maintained butsensing function can be temporarily disabled.

During the postoperative care the deviceshould be reset to the preoperative settings,re-enabled if necessary and re-interrogatedto ensure proper function for discharge (48).Failure to re-establish tachyarrhymia therapyafter the procedure defeats the purpose ofprotecting the patient from lethal ventriculartachycardias (48).

To decrease the risk of aspiration pneumoniafrom gastric regurgitation, NPO (or bymouth orders) are enforced

Nothing Per Os (NPO) is a precaution thatanaesthesiologists use to decrease the risks ofmorbidity or mortality. NPO is prescribed tolower stomach acidity and gastric fluid vol-ume before the operation in order to decreasethe risks of aspiration pneumonia, which isa cause of morbidity from Acute Respira-tory Distress Syndrome and mortality frommultiple organ failure (49). Poor oral hygieneespecially in debilitated patients who can notcare for their own mouths has also beenassociated with aspiration pneumonia (50,51).Patients with dysphagia should have swallow-ing studies to evaluate the need for feeding

tubes (50,51). However, the risk of pulmonaryaspiration needs to be balanced with the risksof excessive NPO status leading to dehydrationand starvation.

Recent studies have linked prolongedpreoperative fasting periods to problems suchas irritability, headache, emesis, hypotension,hypovolaemia and hypoglycaemia (52–55).

Key Point

• wound patients typically havecomorbidities which need tobe addressed prior to thestart of the debridement, manyrequiring hospital admission formedical optimization

Therefore, NPO orders should be accordingto the ASA guidelines which serve as recom-mendations that can be adopted to fit clinicalneeds and constraints (56). What one eats ordrinks makes a difference in regards to NPOorders and anaesthesia. Therefore, ASA guide-lines call for a fasting period for clear liquids(water, fruit juices without pulp, carbonatedbeverage, clear tea, black coffee, etc.) of atleast 2 hours and non human milk and ora light meal (toast and clear liquids) of atleast 6 hours prior to anaesthesia (56). The con-tent and make-up of a heavier meal needsto be accounted for because it increases thegastric emptying time (56). Emergency caseswith full stomachs or patients with abnor-mal gastric emptying or lower oesophagealsphincter function require special approachesto airway management which include rapidsequence induction with intubation, awakeintubation or regional anaesthesia withoutsedation.

IV fluids and medications are administeredpreoperatively for inpatients, diabetics andthose who need medications

Wound patients typically have comorbiditieswhich need to be addressed prior to thestart of the debridement, many requiringhospital admission for medical optimisation.Oral medications should be converted to theIV equivalent unless an ’NPO except Meds’guideline is appropriate for the patient and isconsistent with institutional policies.

These medications can include orally admin-istered antibiotics, antihypertensives, antico-agulants, antiplatelets, oral hypoglycaemicsanalgesics, antidepressants, antivirals and oth-ers that may change the risk of developingperioperative complications. Patients with dif-ficult vascular access can undergo special pro-cedures preoperatively like ultrasound guidedperipherally inserted central catheter (PICC)line insertion which can save operating roomtime.



All patients are monitored intraoperativelyaccording to ASA standardsAll cases of sharp, surgical debridement in theoperating room use anaesthesia services whichapply the ASA standards for monitoring. Incontrast to a ’local case’ where ’local anaes-thesia’ is administered by the surgeon andmonitoring is by non anaesthesia personnelwho may or may not have other proceduralresponsibilities. The ASA has two standards forbasic anaesthesia monitoring. One standard isbased mainly on physical examination by a cer-tified anaesthesia provider. That individual’ssole responsibility is observing the mucosalcolour, movement of the chest wall, rate anddepth of respirations, presence of shivering ordiaphoresis and response to painful stimuli ofthe patient for the duration of the procedureand anaesthesia care (57). The other standardis the continuous monitoring of oxygenation,ventilation, circulation and temperature (57).When the ASA standards are not followed,there is a 17·7% rate of complications (58).

Quantitative oxygenation assessment andcontinuous monitoring with pulse oximetry isbased on the strong conviction that oxygendelivery and aerobic metabolism is mostbeneficial to the patient (59). Because of itsease of interpretation and continuous nature,pulse oximetry is used almost universally (57).Pulse oximetry does not replace monitoringspontaneous ventilation using observation ofchest movement, auscultation of breath soundsand/or capnography (60). Capnography iseffective in assessing airway patency andrespiratory rate. The change of an end tidalcarbon dioxide concentration waveform canindicate an abnormality such as an airwayobstruction and/or apnoea (61).

Proper intraoperative monitoring standardsof circulation require a continuous electrocar-diogram (ECG) display, heart rate, pulse andarterial blood pressure measurements recordedat least every 5 minutes. The ECG Lead II canbest detect atrial dysrhythmias (62) and in com-bination with V5 provide the best sensitivityfor ischaemia recognition short of transoe-sophageal echocardiography (63,64).

Pulse can be assessed by physical examina-tion (palpitation, auscultation) or by technolog-ical monitoring (oximetry or invasive pressuremeasurement) (59). Heart rate measured bythe ECG (voltage) can display a normal num-ber during pulseless electrical activity (PEA)

or electrical mechanical dissociation. Causesof PEA include hypovolaemia, hypoxaemia,hyperkalaemia, acidosis, myocardial infarc-tion, pneumothorax, pericardial tamponadeand pulmonary embolism. Therefore, pulseshould be routinely measured by plethesmog-raphy with pulse oximetry. The pleth signal isreassuring when present, but may be absentfor a variety of reasons ranging from artefact tocardiac arrest. In general, adequate perfusion tothe finger tips or ear lobes suggests adequateperfusion to the vessel rich group includingbrain, heart and liver.

ASA standards recommend temperature tobe monitored (57). Although MH is rare, itis potentially fatal. Fever associated with sys-temic inflammatory response syndrome (SIRS)or sepsis can be seen in the occasional infectedpatient. Hypothermia is a daily risk in theoperating room because the cold physicalenvironment and heat loss factors includingconduction, convection, radiation and evapo-ration. Neuroaxial blocks and general anaes-thesia impair the patient’s ability to maintaincentral autonomic thermoregulatory controland peripheral thermogenesis (65). Sedativesadministered such as propofol (66,67), mida-zolam (68,69) and opioids (70,71) reduce vaso-constriction and decrease shivering thresholds,furthering hampering thermogenesis.

This protocol also recommends glucose man-agement to prevent and treat hypoglycaemiaor hyperglycaemia which has negative conse-quences for wound infections (72) and a linearcorrelation with death rates (73). Even thoughBIS (bispectral EEG) and EMG monitoring arenot required, the use of brain monitors can helpoptimise hypnotic drug titration for deep seda-tion and general anaesthesia. Given the riskof awareness during surgery when using neu-romuscular blockade, BIS monitoring is highlyrecommended for general anaesthetics. BIS val-ues less than 70 are associated with a chance ofrecall less than 1 in 1 million. Extremely low BISvalues with high suppression ratios are unde-sirable and can increase risk of mortality (74).The question has been raised as to whether weuse regional anaesthesia with sedation? If not,how do patients tolerate hearing the eventsin the OR? Patient-centred care challenges usto be concerned about patient satisfaction andemotional needs in the operating room. Seda-tion should be titrated to the patient’s needs.Some patients prefer to be ’wide awake’ as



long as they do not feel pain. The sense of con-trol gives them comfort. Other patients havefears of mutilation and aversion to the smellof burning flesh from the cautery so they pre-fer to be ’asleep’. Other patients simply wantto enjoy the good feeling of IV anaestheticsadministered in a safe environment. The pre-operative assessment provides the strategy forsedation when using regional anaesthesia. The’events’ in the OR can be more pleasant forthe awake patient with a warm, nurturingenvironment cultivated by empathetic staff. Inmost operating rooms, the ’events’ are routinefor staff, but unusual for most patients exceptthose who have frequent surgical procedures.Catastrophic events are uncommon so ’drama’is usually unnecessary.

Regional anaesthesia (local, peripheral orcentral) with sedation (none, light or deep) isadministered as the default regimen withgeneral IV and/or inhalational agents usedwhen blocks are not carried outThe approach to the anaesthesia techniqueis influenced by the patient position duringsurgery. For example, sacral ulcers can bedebrided in the lateral position or the proneposition. The prone position requires an extralevel of assessment and concern about airwaymanagement and ventilation. What about theissues of airway management of the pronepatient needing debridement of a sacral pres-sure ulcer? The priorities for airway manage-ment include maintenance of airway patency,oxygenation and ventilation. The more seda-tion required for the case, the greater thelikelihood of apnoea and/or airway obstruc-tion. Paraplegics or patients with spinal anaes-thesia can be positioned prone while awaketo ensure comfort and adequate ventilationbecause positioning can be problematic. Whenantinociception is adequate, minimal sedationis required. Many anaesthesiologist will useendotracheal intubation for all prone cases toavoid the challenges of airway managementwithout an endotracheal tube (ET). We hypoth-esise that neuromuscular blockade commonlyused for intubation presents unnecessary prob-lems with muscular weakness in debilitatedpatients which could lead to respiratory failure.This is a topic for a separate paper.

Patients with spinal cord injury alwaysneed individualised assessment of their anaes-thetic need. The unique pattern of impairment

including spasticity, may determine the strat-egy chosen to maintain comfort and home-ostatsis. In our practice, neuropathic patientsespecially paraplegics and quadriplegics aswell as those with regional blocks such as localor spinal require little or no sedation and canbreathe spontaneously. Chest rolls are usedto allow diaphragmatic offloading to preventrestricted ventilation. Deep sedation or gen-eral anaesthesia prompts most practitionersto intubate patients for the prone position.In contrast, the lateral position provides bet-ter access to the airway and more favourablemechanics for spontaneous ventilation com-pared with the prone position. Sedating apatient for sacral debridement in the lateralposition is similar to colonoscopy assumingthere is antinociception.

In the absence of complete central neu-ropathy like paraplegia, antinociception wouldbe needed pharmacologically using sodiumchannel blockade. Regional blocks can be cat-egorised as local infiltration blocks, peripheralblocks or central blocks (Figure 1). One regionalanaesthesia regimen uses a local infiltrationblock with sedation as needed for amnesiaand hypnosis. If no open wound is present,a transcutaneous injection of sodium channelblocker like 1% lidocaine is performed priorto the incision. In the presence of an openwound, local anaesthesia can be administeredtopically or subcutaneously. The subcutaneoustechnique for local anaesthesia injection intothe wound edge is less painful compared withtranscutaneous injection (75). When injectinglocal anaesthesia to the skin, it is important

Figure 1. Regional anaesthesia hierarchy for sacral pressureulcers. © O’Neill & Ayello 2012



to deposit the anaesthetic in or barely underthe dermis layer, otherwise the small, unmyeli-nated nociceptive fibres that populate the epi-dermis will not be anaesthetised (76). It isdifficult to fully anaesthetise infected tissuewith Lidocaine. Topical agents do not penetratedevitalised tissues. Locally infiltrated sodiumchannel blockers require adequate distributionof the drug to the afferent nerves. Infected anddevitalised tissues may be difficult to ’numb’using local techniques. Regional techniquesincluding peripheral and central block or gen-eral anaesthesia are alternatives to local infiltra-tion when drug tissue distribution factors exist.

The total dose of local anaesthetic adjustedfor body weight should be below the limit fortoxicity. Local anaesthetic toxicity needs to beaccounted for as high plasma concentrationsof these drugs can cause seizures, respiratoryfailure and cardiovascular collapse (77). Thesystemic effects are noted because sodiumchannels exist in both nerves and musclesincluding the heart. The total dose of sodiumchannel blocker combined with the rate ofadministration, absorption and eliminationcould influence the risk of complications (24).

Peripheral blocks or central blocks canalso be used for pressure ulcers. Paraver-tebral blocks are more commonly used fortrochanteric or ischial pressure ulcers com-pared with sacral pressure ulcers. Centralblocks for sacral procedures include spinalor epidural blocks for antinociception withsedation as needed. Lidocaine, bupivacaineand tetracaine are the three most commonspinal blockade drugs. Bupivacaine has almostreplaced the use of lidocaine because less inci-dence of transient neurological symptoms post-operatively (78–80). Intrathecal opioids havelittle effect on haemodynamics, but can causerespiratory depression. Epidural blocks requirehigher drug dosages and volumes comparedwith spinal blocks because the dura materlimits the drug distribution to the cerebralspinal fluid. Lidocaine is the most com-mon epidural anaesthetic but bupivacaineand ropivacaine can also be used as longerlasting local anaesthetics. However, centralblocks with sodium channel blockade can leadto sympathectomy, bradycardia, decreasedpreload, decreased afterload, decreased car-diac output and hypotensison (24). Therefore,central blockades require adequate vascularaccess, fluid administration and vasopressors

(phenylephrine, ephedrine or norepinephrine)as needed. The location of drug delivery influ-ences the efficacy and complication rate (81,82).

Regional anaesthesia with sedation asneeded is the default regimen of this protocolwith general anaesthesia as a second choice.Sedation should be used for amnesia or hyp-nosis if the patient has anxiety that wouldprevent a safe procedure. Light sedation usingmidazolam (0·01 mg kg IV PRN) and fentanyl(0·5 μg/kg IV PRN) for analgesia is the sug-gested combination. For a patient with sleepapnoea or a difficult airway, a dexmedeto-midine (0·2–0·6 μg/kg/minute) (83) infusioncould be used because it produces less res-piratory depression (84). When deep sedationand hypnosis become necessary, the light seda-tive drugs should be used in combinationwith propofol (25–200 μg/kg/minute) plus orminus ketamine (20–50 μg/kg IV PRN).

The Pro-Etom InfusionTM (30 ml total at0·6–1·2 ml/kg/hour) is used by some anaes-thesia providers to blend the benefits ofpropofol (200 mg in 20 ml) and etomidate(20 mg in 10 ml). Methohexothal infusion(25–200 μg/kg/minutes) can be used whenpropofol is not desirable for deep seda-tion (85). Opioid and non opioid (ketorolacor acetaminophen) analgesic agents have beenused to supplement sedative anaesthetics toincrease patient comfort during surgery (86).

When antinociception fails to be achievedwith underlying neuropathy or a sodium chan-nel blockade, the anaesthesiologist should usegeneral anaesthetics. Total intravenous anaes-thesia (TIVA) with propofol (25–200 μg/kg/minutes), fentanyl (0·5 μg/kg IV PRN) orremifentanil (25–200 ng/kg/minutes) plus orminus ketamine (20–50 μg/kg IV PRN) is oneoption. Another option is to balance general IVagents with the inhalational agents (isoflurane,sevoflurane or desflurane). This technique maybe preferred when the patient presents to theoperating room with an ET or tracheostomy.Inhalational agents could be used with or with-out blocks or IV administration. However, thistechnique using sevoflurane and nitrous oxidehas a slower induction time compared withTIVA (87). In a pure inhalational anaesthesiatechnique, there is no background IV anal-gesia for postoperative pain control (88). Ascommonly performed with paediatric patients,inhalational induction with sevoflurane withnitrous oxide can be used to obtain vascular



access if the adult patient presents with exces-sive anxiety or needle phobia (89).

Neuromuscular blockade should only beused as a last resort as a part of generalanaesthesia. Succinycholine is extremely usefulfor rapid sequence induction and treatment oflaryngospasm. Short acting succcinylcholine, adepolarising muscle relaxant, can have severeside effects like hyperkalaemia, especiallyin patients with extrajunctional nicotinicreceptors from disability. Although uncom-mon, succinylcholine can trigger MH leadingto hypercarbia, hypoxia, hyperthermia, hyper-kalaemia and death even if treated with dantro-lene upon recognition of the symptoms (90). Inaddition, non depolarising blockers such asrocuronium, vecuronium and cis-atracuriumcan be associated with residual neuromus-cular weakness which can increase risks ofrespiratory failure in debilitated patients withsarcopenia.

Goals of airway management are to maintainairway patency, oxygenation and ventilationusing the minimum invasiveness of airwaydevicesThis protocol recommends that airway man-agement without tracheal intubation be con-sidered whenever possible on the premise thatcomplications associated with intubation areworth minimising. These airway managementtechniques include simple face mask ventila-tion, oral and nasal airways and supraglotticdevices like laryngeal mask airways (LMA).However, this protocol acknowledges that ETsor surgical airways (existing tracheostomies orrarely, emergency cricothyroidotomy) may benecessary occasionally.

Lets review respiratory physiology and thedifference between oxygenation and ventila-tion (Figure 2). Catabolism, which is half ofmetabolism, involves oxidation of fuels suchas glucose, amino acids and fatty acids to pro-duce chemical energy in the form of adenosinetri-phosphate (ATP). The metabolic rate canbe estimated by oxygen consumption (VO2)and/or carbon dioxide production (VCO2).Oxygen delivery represents the transport ofinhaled oxygen to the cellular mitochondria foroxidative phosphorylation. The carbon dioxidefrom the decarboxylation steps in the Kreb’stricarboxylic acid cycle gets transported to thealveoli via the venous blood for diffusion, dilu-tion and exhalation. This ’fuel exhaust’ can be

measured by infrared spectroscopy and othertechniques at the airway as an index of air-way patency and quality of ventilation withoutmeasurement of an arterial blood gas.

Continuous assessment of oxygenation andventilation is extremely important whensedation is given. Vigilance is essential toallow early detection, early intervention andavoiding catastrophes such as hypoxic braininjury from airway obstruction, apnoea and/orcardiac arrest.

Ventilation methods are classified into threecategories (Figure 3). Unsupported negativepressure spontaneous ventilation is most nat-ural which can be maintained with any airwaydevice or circuit. Positive pressure ventilationrequires a breathing system that generates apressure above atmospheric pressure to over-come resistance and compliance factors. Man-ual ventilation using the circle system withanaesthesia bag, the ambu bag (manual resus-citator), or Jackson Rees circuit bag providespositive pressure by the hand of the anaes-thesia provider. Controlled mechanical venti-lation provides positive pressure ventilationusing either volume control or pressure con-trol using either an ICU ventilator or standardanaesthesia machine. The breaths can be eithermandatory (set number machine triggered) orspontaneous (patient triggered). Synchronisa-tion modes are designed to prevent patient-ventilator asynchrony which can present as thepatient ’fighting the ventilator’ and/or as ven-tilator associated lung injury like barotrauma.Newer anaesthesia machines have sensors andother features which allow them to functionlike sophisticated ICU ventilators.

Room air light sedation techniques allowpulse oximetry to be an index of hypoven-tilation as well as hypoxaemia based on theoxygen-haemoglobin saturation curve. Hyper-carbia will cause desaturation when the alveolicontain 78% nitrogen (room air), but may notwhen alveolar oxygen is higher (91). Whensupplemental oxygen is used, capnographyshould be monitored to ensure airway patencyand respiration rate (Figure 4 – capnography).An abnormality in the CO2 wave can be arte-fact, central apnoea or airway obstruction (61)(Figure 4B – capnography). The disruption ofthe waveform should prompt immediate actionfor assessment and intervention.

Simple face masks and nasal cannulacan promote small increases in the fraction



Figure 2. Review of respiratory physiology. © O’Neill & Ayello 2012

of inspired oxygen (FiO2) which helpsto alleviate hypoxaemia (92,93). Simple facemasks provide supplemental oxygen to boththe nose and mouth while providing theopportunity for superior gas analysis com-pared with nasal cannula (Figure 5 – simpleface mask with gas sampling). Mouth breathersperform better with simple face masks. Exhaledwater vapour accumulated on the face maskduring ventilation can be detected, but thisprotocol still suggests digital and graphicaldisplay of ventilation via capnography. Thisprotocol recommends clear-plastic masks withlarge volume, low-pressure cushions which

provide an easy seal while simultaneouslyallowing for easy observation of condensationand evaporation from ventilation or the unex-pected vomited stomach contents. A mask witha strap can be used to achieve a tighter seal toprevent room air dilutions of 100% O2 and per-mitting positive pressure ventilation to treatairway obstructions, apnoea and/or hypoven-tilation. Using the circle system and anaesthesiabag, one can measure the expired tidal volumesand airway pressure associated with manual orcontrolled ventilation. An ambu bag is requiredto be present in all procedure rooms for all casesas a low-tech resuscitation device.



Figure 3. Classification of ventilation techniques. © O’Neill &Ayello 2012

If a seal between the mask and the face can-not be properly achieved alternative methodsmust be implemented. Failed seals can occur asa result of patient intolerance (cannot stand themask on their face) which can lead to extendedperiods of time with the mask removed orpoorly positioned to increase comfort (94).Nasopharyngeal oxygen via nasal cannulapositioned at the exterior nostrils is a safeand comfortable alternative to face masks (94).Newer nasal cannula models have gasexchange analysis ports in their design whichmakes them more desirable than older modelswhich had limitations like monitoring CO2.

The evolution of supraglottic airway devicesincluding the LMA and I-Gel have been anadvancement in anaesthesia (Figure 6 – airwaydevices). Supraglottic airway devices keep thetongue and pharyngeal soft tissue away fromthe lumen of the trachea to maintain air-way patency. This is important as the role ofthe anaesthesiologist is dynamic managementand multitasking. As the anaesthesiologist nolonger has to manually maintain the adequateseal and mask fit with chin lift, this freesup the anaesthesiologist’s hands which canthen be used to maintain IVs, preparation andadministration of drugs and even fulfil other

responsibilities including contemporaneousdocumentation (95).

Why use an LMA over an ET? Supra-glottic airway can be inserted without usingneuromuscular blockade which is an advan-tage compared with tracheal intubation (96). Inaddition, non anaesthesiologists are typicallymore successful at placing LMAs comparedwith performing tracheal intubations (97). Theabsence of neuromuscular blockade can allowspontaneous ventilation which is desirable,especially in an outpatient surgical settingfor optimal drug titration and faster emer-gence (95). Patients receiving general anaes-thesia in the outpatient setting for LMAscompared with ETs have been shown to haveshorter PACU stays because the drug concen-trations are more favourable with fewer sideeffects (96).

ETs with general anaesthetics using eitherspontaneous or positive pressure ventilationadd a level of safety because respiratorydepression and loss of reflexes are expected.

In typical patients, usually the anaesthesiolo-gist will induce anaesthesia prior to intubationwhich leads to amnesia, apnoea and areflexia.In high risk airway patients, where intubationmay be challenging or difficult, spontaneousventilation is maintained until ET placementis confirmed to decrease risk of hypoxaemia.Therefore in high risk airway patients, the intu-bation plan is opposite that the usual plan(Table 3). ETs are commonly inserted usingdirect laryngoscopy for placement below thevocal cords and above the tracheal carina.Video scopes such as the glide scope or fibreop-tic bronchoscopes may be necessary for somechallenging intubations. Like the LMA, ETsmaintain airway patency while freeing thehands of the anaesthesiologist to attend to otherresponsibilities. In addition to reliably prevent-ing pharyngeal collapse and laryngospasm, theET with the inflatable cuff decreases the riskof pulmonary aspiration of the gastric contentsand saliva (Figure 6 – LMA versus ET).

Surgical airways remain the last resort.Elective patients with respiratory failure orsevere dysphagia may require tracheostomy.Emergency cricothyroidotomy is the treatmentof choice for the ’unable to intubate–unableto ventilate’ scenario which the ASA difficultairway algorithm was designed to avoid.

Induction of general anaesthesia for intuba-tion results in amnesia, apnoea and areflexia.



(A)

(B)

Figure 4. (A) Capnography part 1, endotracheal tube mask and (B) capnography with abnormalities. © O’Neill & Ayello 2012

Figure 5. Face mask gas sampling and oxygen delivery.© O’Neill & Ayello 2012

Consequently, there is a risk of airway obstruc-tion, hypoxaemia and hypercarbia (respira-tory acidosis) if mask ventilation with oxygenand/or intubation are not successful. There aretwo major approaches to endotracheal intuba-tion (Table 3): plan A is induction of anaesthe-sia followed by intubation; Plan B is intubationfollowed by induction of anaesthesia. Plan Ais most commonly used because most patients

are NPO and are likely to be easy to maskventilate and intubate easily using direct laryn-goscopy. Plan B is used for the challenging ordifficult intubation because spontaneous ven-tilation with maintenance of airway reflexesminimises the risk of hypoxaemia. The sponta-neous breathing or so-called ’awake’ techniqueusually involves airway topicalisation withsodium channel blockers such as lidocaine andsedation (midazolam, fentanyl, droperidol,dexmedetomine, ketamine and/or propofol)for comfort and cooperation. Once the ETplacement is confirmed by the usual methods,induction of anaesthesia can proceed withoutthe risk of airway obstruction.

All patients are monitored postoperatively forthe duration appropriate to their acuity

Generally, patients are transferred to thePACU postoperatively. The PACU shouldbe staffed with the attending anaesthesiolo-gist, trained recovery room nurses and othersupport personnel, who have a comprehen-sive understanding of possible complications



(A) (B)

Figure 6. Airway devices: Head to head comparison. (A) Supraglotic laryngeal mask. (B) Endotracheal tube.

Table 3 Airway management strategies for intubation© O’Neill & Ayello 2012

Plan A Induce anaesthesia, then intubatePlan B Intubate, then induce anaesthesia

and treatment protocols (89,90). Patients aremonitored until they meet the discharge cri-teria (Table 4). The ASA guidelines as sum-marised by the Aldrete score state that priorto PACU discharge, patients should be atbaseline neurological status (awake and alert,if so preop) with vital signs within acceptablelimits (98). Patients need to meet an acceptablehospital specific score of a set of criteria definedby where the procedure was performed. Foroutpatients, a responsible adult should bepresent to take the patient home if accept-able and a written set of instructions should beprovided with the patient (98). Although theanaesthesiologist may occasionally choose tobypass the PACU, patients from the operatingroom usually go to the PACU prior to transferto the floor, ICU or discharged home.

When the anaesthesiologist decides, it maybe possible to ’fast track’ the recovery patientsby bypassing the PACU (Table 4) (99). Thisapproach is usually used for patients whohad ambulatory surgery or inpatients withlocal anaesthesia with minimal sedation orprolonged PACU hold times. PACU bypassis a cost effective, safe and efficient alterna-tive to the PACU for these patients (99–102).This technique should only be used when the

Table 4 Basis of assessment for discharge from anaesthesia(Aldrete) © O’Neill & Ayello 2012

1 Haemodynamic stability achieved2 Low risk of blood loss from surgical site3 Baseline neurological status satisfactory4 Low risk of respiratory depression5 Comfortable

anaesthesiologist feels that the patient is atminimal risk for developing any postoperativecomplications.

DISCUSSIONPatients with pressure ulcers are typicallyquite ill and have multiple comorbidities mak-ing wound management and healing a chal-lenge. Debridement is an important componentof wound bed preparation. As debridementremoves non functioning keratinocytes and

Key Point

• patients with pressure ulcersare typically quite ill and havemultiple comorbidities makingwound management and heal-ing a challenge

bioburden, it must be extensive enough toprovide the scaffold for tissue repair and stimu-lation of wound healing. Adequacy of debride-ment to the ’margin of response’ is based on thebiological understanding of the impairmentsto healing of a chronic wound (103). Assur-ing adequacy of debridement requires probingand manipulation of the wound that is painful.Pressure ulcer pain may preclude using somemethods of debridement. Management of painso that enough debridement of the wound canbe undertaken is essential.

Advances in anaesthesiology over thelast two decades including pulse oximetry,



capnography, advanced airway management,as well as, ultrasound guided vascular accessand regional block techniques have improvedpatient safety in the operating room. Althoughthere are inherent risks with anaesthesia, fear ofthe operating room, especially receiving anaes-thesia, should not prevent a wound patientfrom obtaining the surgical debridement theydesperately need to stimulate wound closure.Significantly lower mortality rates for woundpatients who had debridements comparedwith those who did not (2,10,104) suggest thissurgery to be life saving. The use of thisanaesthesia protocol will undoubtedly assistthe attending physicians of wound patientsin securing consent from the patient and per-forming a safe, successful debridement withminimal complications.

Key Points

• management of pain so thatenough debridement of thewound can be undertaken isessential

• significantly lower mortalityrates for wound patients whohad debridements comparedwith those who did not suggestthis surgery to be life saving

• as no literature exists on usinga protocol emphasising regionalanaesthesia with sedation asneeded for operative debride-ment, it is the recommenda-tion that through this proto-col a retrospective chart reviewon outcomes of sacral pres-sure ulcer debridements withregional anaesthesia be per-formed

• a randomised, stratifiedprospective clinical trial withthe use of this protocol is alsosuggested for the future

This anaesthesia protocol promotes thepremise that subspeciality training in woundanaesthesia is advantageous for patients withnon healing wounds like sacral pressure ulcers.As no literature exists on using a protocolemphasising regional anaesthesia with seda-tion as needed for operative debridement,it is the recommendation that through thisprotocol a retrospective chart review on out-comes of sacral pressure ulcer debridementswith regional anaesthesia be performed. Arandomised, stratified prospective clinical trialwith the use of this protocol is also suggestedfor the future.

ACKNOWLEDGEMENTThis work was supported by NIH Grant RO1LM008443-04.

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